Peachman, Gerda NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gerda Marga Peachman Female
Date of Death Age If Veteran of U.S. Armed Forces,
November#, 2014/ 88 War or Dates
}" Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death E Natural Cause 0 Accident n Homicide I I Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
C1
Address
Death Certificate Filed District Number
Register Number
City, Town or Village 5601 :5-eg
®Burial Date Cemetery or Crematory
November 4, 2014 Pine View Cemetery
❑Entombment Address
El Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Z ❑ Removal and/or Held
and/or
EE' Hold Address Pine View Cemetery
Date Point of
❑ Transportation Shipment
0 by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I-; Remains are Shipped, If Other than Above
2 Address
i '
W.
il.: Permission is hereby granted to dispose of the human mains d scribed above as indi ated.
Date Issued .. ) Registrar of Vital Statistics �r��� � / 6)2/ '
(signature)
i/District Number 5601 Place -
certify that the remains of the decedent identified above were disposed of in accordance w this permit on:
in Date of Disposition 11/04/2014 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
n �!
(section)re (lot number) (grave number)
0 Name of Sex n or Person in Charge of Premises 6nJ G qo -c-vck.,0, L t
(please print)
W Signature e. i oe--,,,( Title &-tPCP--(--1.3-r8-4-3D L-13-1-
(over)
DOH-1555 (02/2004)